The Emergency Department Staff Specialists meet at 4.00pm for their weekly meeting. They debrief about the new bunch of interns without realising their gender bias.
‘Julian is a pleasant chap’.
‘He seems very capable and demonstrates great procedural skills, so we should give him ample opportunity to practice.’
‘Nice bloke, Julian, and very likeable. He will do well. I predict surgery or critical care.’
‘He’s just had a baby, so we should congratulate him!’
‘Anita is a bit cold and standoff-ish.’
‘She is not very confident.’
‘I disagree, I think she is a bit overconfident, maybe due to her age?’
‘I wonder if full-time will work out for her, she has school-age kids and all her family are overseas.’
‘She would be best suited for medicine I think, as she is a quiet type.’
Dr. Julian starts his first day as an intern in the Emergency Department. He is 26 years old and finished his medical training with Honours. He has a newborn at home, being cared for by his wife who is also an intern. On arrival to the Emergency Department, he greets a colleague from his previous surgical rotation with a high five. He cannot wait to demonstrate his newly acquired suturing skills. Despite feeling nervous, Julian is in his element and sends out positive and confident energy. He is immediately very liked and given an opportunity to suture a complex arm laceration in Fast Track by his registrar.
Dr. Anita starts her first day as an intern in the Emergency Department. Anita has a degree in Biochemical Sciences and worked as a part-time teacher before starting medical school. She has two children who are eight and ten years old. She is feeling somewhat anxious, as she has been unable to find a part-time intern job and is now obliged to work full-time for the first time in 10 years. However, she received very positive feedback in her previous Geriatrics term and feels confident and excited to start her rotation in the Emergency Department. She performs well on her first day, is mature and professional, with impressive complex case management.
You think these are stereotypes right? Maybe. Or maybe, if you think about it, you actually know a Julian and an Anita. Or, maybe you are one of them?
The feedback from the Staff Specialists is a typical example of implicit and explicit gendered micro-bias. Micro-bias is not malicious. It is an acquired preconception influencing one’s behaviours and interactions. We all succumb to it, subconsciously. Synonyms are micro-inequity, or micro-aggression. The latter sounds less innocent, doesn’t it?
Gender bias, by men and women, is still a persistent issue in medicine. A 2019 JAMA study amongst 43,000 U.S. health professionals demonstrated explicit and implicit biases. These biases associate men with career and women with family. Similarly, healthcare professionals associate men with surgery and females with medicine (1).
In the academic world, double standards are an ongoing roadblock for women. Ross-Macusin et. al. studied the impact of gender as an independent variable on an identical job application. It demonstrated a significant negative impact for females on perceived competence, hireability, mentoring opportunities and starting salary (2). Women are also given more negative feedback as part of performance reviews than men, and found less likeable when successful (3).
There is an inconsistency between genders when given feedback. For instance, performance is being held to typically male trait standards, such as confidence, and assertiveness. ‘He is a boss, but, she is bossy’ (4-6). The opportunity gap is even greater for women who are also parents compared to male parents (7).
As a result of these double standards, women find it more stressful to embrace their assertiveness and often apologise for it. This comes even though we know that in a resuscitation, a team typically performs better when led by clear and direct individuals (8). Women’s self-confidence is compromised. In turn, this leads to increased stress and anxiety, driving some female doctors to leave the field of medicine (9).
The lack of employment, research, and public speaking opportunities, as well as mentorship support, further unbalances the playing field. As a result, we see a markedly uneven gender balance in leadership (10,11). Despite this, extensive literature exists to support the benefits of a diverse workforce on group performance and professional wellbeing. In turn, this benefits our healthcare system significantly (12).
Without awareness of this bias, a person may feel the need to object against the preposterous suggestion that he or she is acting discriminatingly. ‘Damn all the political correctness these days!’ However, it is not about how you feel. It’s about how you make the other feel. Micro-bias results in disempowerment and disadvantage women significantly.
Therefore, it is useful to reflect on day-to-day conversations, keeping an open mind to your own gender lens, and choosing your words with care. The ability to adjust your own behaviours shows vulnerability as well as strength, driving growth and creating an inclusive leadership style. Lead by example, and your environment will follow.
Stanford University School of Medicine offers a free online module on unconscious bias in the academic medicine workplace. Visit https://online.stanford.edu/courses/som-ycme0027-unconscious-bias-medicine-cme. Have a look, and challenge your colleagues.
You can contribute to a small step towards reaching true equity.